Client Receipt of ICC Client Handbook and Notice of Privacy Practices Form

ICC Inc. Media Services Portal: Forms

This form is part of the Client Intake Packet. It was last updated May 17, 2021.

Innovative Counseling & Consulting, Inc.

Client Receipt of ICC Client Handbook
& Notice of Privacy Practices

Instructions: Please enter your initials in the field following each statement to acknowledge receipt of the Handbook that contains copies of the numbered information.

Part I: The Contents

1. ICC Philosophy

2. ICC Mission Statement

3. ICC Core Values

4. Confidentiality and Legal Status Policy

5. Client Rights and Responsibilities Policy

6. Grievance / Appeal Process (Policy)

7. Emergency / After Hours Policy

8. Outpatient Counseling and Psychotherapy Services Service Description

9. Behavioral Health Intervention Services Service Description

10. Evaluations Services Service Description

11. Notice of Privacy Practices / HIPPA

12. Documents 1 – 11 listed above have been reviewed. I understand I may ask questions at any time for further clarification of any part of the ICC Client Handbook.

Part II: Signature

By clicking “Submit,” you give us permission to email you.

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